Information and knowledge play an important role in the safe care of patients. Librarians and other information professionals are particularly well suited to partner with their institutions and patients to contribute to safe care.

Thursday, April 04, 2013

Failing in Order to Succeed. Part 3

Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).

The ability
for organisations to reap the benefits of this unique skill concentration is,
alas unrealized at this time. Librarians and other information experts must
understand their organisation’s culture to apply this expertise to enrich its
learning from failure. An appreciation of the depth of what really happened
rather than taking a more superficial or cursory approach is required for
EI&K to genuinely be used to realize system-oriented learning after a
stumble.

The real
loss is when failures replicate: both within the same organisation and amongst
those who need to learn from the experiences of others. For example, when
failures in medical care occur, an awareness of that incident is thought to
help minimize its occurrence elsewhere. “It won’t happen here” mentality,
problem denial and ignorance, and “doesn’t apply to me so it’s not useful”
approaches can scuttle chances to learn from the misfortune of others. True
tragedy can occur. Such blockades can be breeched through effective evidence,
information and knowledge sharing.

Next actions:

These apply
to both organisational and individual “learning from failure” commitments

·Design time to reflect on what was
done well and what could have been improved into processes. If the habit of
thinking about and discussing failure as a learning opportunity is hardwired in
to projects throughout their lifetime, the tougher ones that result in delay,
disruption and disaster will be more effectively and expertly dealt with.

·Dig deep to get to the second story
of failure / avoid blame and look at problems from a systems view

·Walk the talk: practice at home, at
school, at social events. Lots of little failures happen often so they’ll be
plenty of opportunities to hone the skills.

·Review additional reading and discuss
what is provocative with others.

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About Me

Lorri Zipperer, MA is the principal at Zipperer Project Management, in Albuquerque, New Mexico. She works with clients to provide patient safety information, knowledge sharing and general project management guidance. She was a founding staff member of the National Patient Safety Foundation as the information project manager.